Wide QRS complex tachycardias

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Wide QRS complex tachycardias

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Differential Diagnosis of Tachycardia with Wide QRS Complex

  1. A regular tachycardia with a rate of 120 to 200 BPM with a QRS duration of .12 seconds or longer may be due to:
    • Paroxysmal VT
    • Supraventricular tachycardia with abnormally wide QRS
      1. Sinus tachycardia
      2. SA nodal reentrant tachycardia
      3. Paroxysmal atrial tachycardia
      4. Intraatrial reentrant tachycardia
      5. Atrial flutter with 2:1 conduction and occasional 1:1 conduction
      6. AV nodal reentrant tachycardia
      7. Automatic junctional tachycardia
      8. AV reentrant tachycardia using a bypass tract

Differential Diagnosis of Wide QRS Complexes

  1. Aberrant ventricular conduction
  2. Preexisting left or right bundle branch block
  3. Preexisting nonspecific IVCD
  4. Antegrade conduction through the bypass tract in patients with WPW

Clues to the Diagnosis of VT

  1. Morphology of Premature Beats During Sinus Rhythm:
    • Previous EKG may show preexisting IVCD.
    • If PVCs are present, and if the morphology of the arrhythmia is the same, then it is likely to be ventricular in origin.
    • If there are PACs with aberrant conduction, then the origin of the arrhythmia may be supraventricular.
  2. Onset of the Tachycardia:
    • Diagnosis of SVT made if the episode is initiated by a premature P wave.
    • If the paroxysm begins with a QRS then the tachycardia may be either ventricular or junctional in origin.
    • If the first QRS of the tachycardia is preceded by a sinus p wave with a PR interval shorter than that of the conducted sinus beats, the tachycardia is ventricular.
  3. AV Dissociation:
    • Although is highly suggestive of VT, it may also be seen in junctional tachycardias with retrograde block.
  4. Morphology of the QRS Complexes and QRS Axis:
    • 80 to 85% of aberrant beats have a RBBB pattern, but ectopic beats that arise from the LV have a similar morphology.
    • The finding of a positive or negative QRS complex in all precordial leads is in favor of ventricular ectopy.
    • A QRS duration of > .14 seconds (A Wellens criterion)
    • Left axis deviation (A Wellens criterion)
    • A monophasic or biphasic RBBB QRS complex in V1. But none of their patients with SVT had a preexisting RBBB. Therefore, this finding is of limited importance. (A Wellens criterion)
  5. Akhtar studied 150 patients with a wide complex tachycardia. The following were helpful in the diagnosis of VT:
    • all patients with VT had a QRS duration > 120 msecond.
    • QRS > .14 with a RBBB, QRS > .16 with LBBB.
    • V1 - V6 all show a positive deflection.
    • QRS axis between -90 and + 180 degrees.
    • The QRS complexes have a LBBB but the QRS axis is rightward.
    • In patients with preexisting bundle branch block, there is a change in the QRS pattern during the tachycardia.
  6. Capture beats:
    • Rare, but one of the strongest pieces of evidence in favor of VT.
    • Aberrancy rarely follows a beat of such short cycle length.
  7. Fusion beats:
    • Rare but also strongly suggests VT.
  8. Vagal Stimulation:
    • VT is not affected by vagal stimulation.
    • May terminate reentrant arrhythmias
  9. Atrial pacing:
    • A pacing wire is placed in the RA and the atrium is stimulated at a rate faster than the tachycardia.
    • If ventricular capture occurs and the QRS is normal in duration, then one can exclude the possibility of aberrant conduction.
  10. His bundle recording:
    • In SVT, each QRS is preceded by a His bundle potential.
    • In VT there is no preceding His deflection.
    • The retrograde His deflection is usually obscured by the much larger QRS complex.
An overview of ventricular tachycardias, follow the wide complex tachycardia flowchart
example regularity atrial frequency ventricular frequency origin (SVT/VT) p-wave effect of adenosine
Wide complex (QRS>0.12)
Ventricular Tachycardia Vt small.svg regular (mostly) 60-100 bpm 110-250 bpm ventricle (VT) AV-dissociation no rate reduction (sometimes accelerates)
Ventricular Fibrillation Vf small.svg irregular 60-100 bpm 400-600 bpm ventricle (VT) AV-dissociation none
Ventricular Flutter Vflutt small.svg regular 60-100 bpm 150-300 bpm ventricle (VT) AV-dissociation none
Accelerated Idioventricular Rhythm Aivr small.svg regular (mostly) 60-100 bpm 50-110 bpm ventricle (VT) AV-dissociation no rate reduction (sometimes accelerates)
Torsade de Pointes Tdp small.svg regular 150-300 bpm ventricle (VT) AV-dissociation no rate reduction (sometimes accelerates)
Bundle-branch re-entrant tachycardia* Bb reentry small.svg regular 60-100 bpm 150-300 bpm ventricles (VT) AV-dissociation no rate reduction
*) Bundle-branch re-entrant tachycardia is extremely rare

Differential Diagnosis of Wide QRS Complex Tachycardia

  1. The following favor the diagnosis of VT:
    • AV dissociation
    • RBBB with QRS > .14, or LBBB with QRS > .16
    • QRS axis in RUQ between -90 and +180 degrees
    • Positive QRS in all the precordial leads (V1-V6)
    • LBBB with a rightward axis
    • LBBB with the following QRS morphology
      1. R wave in V1 or V2 > 0.03 second
      2. any Q wave in V6
      3. Onset of the QRS to nadir of the S wave in V1 > 0.06 seconds
      4. Notching of the S wave in V1 or V2
    • Capture beats, fusion beats
    • QRS morphology identical to that of premature ventricular beats during sinus rhythm

Clinical Correlation

  1. Most patients with VT have organic heart disease.
  2. Post MI VT is associated with a doubling of the risk of death.
  3. This was an a risk factor independent of poor LV function.
  4. VT can be seen with reperfusion, but an accelerated idioventricular rhythm is more common.
  5. Digoxin intoxication is a common cause. Other antiarrhythmics, phenothiazines, TCAs, and pheochromocytoma may also cause this.
  6. Cardiac catheterization, DC countershock, following repair of congenital lesions, and the hereditary QT prolongation are all associated with VT.


Cost Effectiveness of Wide QRS complex tachycardias

| group5 = Clinical Trials Involving Wide QRS complex tachycardias | list5 = Ongoing Trials on Wide QRS complex tachycardias at Clinical Trials.govTrial results on Wide QRS complex tachycardiasClinical Trials on Wide QRS complex tachycardias at Google


| group6 = Guidelines / Policies / Government Resources (FDA/CDC) Regarding Wide QRS complex tachycardias | list6 = US National Guidelines Clearinghouse on Wide QRS complex tachycardiasNICE Guidance on Wide QRS complex tachycardiasNHS PRODIGY GuidanceFDA on Wide QRS complex tachycardiasCDC on Wide QRS complex tachycardias


| group7 = Textbook Information on Wide QRS complex tachycardias | list7 = Books and Textbook Information on Wide QRS complex tachycardias


| group8 = Pharmacology Resources on Wide QRS complex tachycardias | list8 = AND (Dose)}} Dosing of Wide QRS complex tachycardiasAND (drug interactions)}} Drug interactions with Wide QRS complex tachycardiasAND (side effects)}} Side effects of Wide QRS complex tachycardiasAND (Allergy)}} Allergic reactions to Wide QRS complex tachycardiasAND (overdose)}} Overdose information on Wide QRS complex tachycardiasAND (carcinogenicity)}} Carcinogenicity information on Wide QRS complex tachycardiasAND (pregnancy)}} Wide QRS complex tachycardias in pregnancyAND (pharmacokinetics)}} Pharmacokinetics of Wide QRS complex tachycardias


| group9 = Genetics, Pharmacogenomics, and Proteinomics of Wide QRS complex tachycardias | list9 = AND (pharmacogenomics)}} Genetics of Wide QRS complex tachycardiasAND (pharmacogenomics)}} Pharmacogenomics of Wide QRS complex tachycardiasAND (proteomics)}} Proteomics of Wide QRS complex tachycardias


| group10 = Newstories on Wide QRS complex tachycardias | list10 = Wide QRS complex tachycardias in the newsBe alerted to news on Wide QRS complex tachycardiasNews trends on Wide QRS complex tachycardias</small>


| group11 = Commentary on Wide QRS complex tachycardias | list11 = Blogs on Wide QRS complex tachycardias

| group12 = Patient Resources on Wide QRS complex tachycardias | list12 = Patient resources on Wide QRS complex tachycardiasDiscussion groups on Wide QRS complex tachycardiasPatient Handouts on Wide QRS complex tachycardiasDirections to Hospitals Treating Wide QRS complex tachycardiasRisk calculators and risk factors for Wide QRS complex tachycardias


| group13 = Healthcare Provider Resources on Wide QRS complex tachycardias | list13 = Symptoms of Wide QRS complex tachycardiasCauses & Risk Factors for Wide QRS complex tachycardiasDiagnostic studies for Wide QRS complex tachycardiasTreatment of Wide QRS complex tachycardias

| group14 = Continuing Medical Education (CME) Programs on Wide QRS complex tachycardias | list14 = CME Programs on Wide QRS complex tachycardias

| group15 = International Resources on Wide QRS complex tachycardias | list15 = Wide QRS complex tachycardias en EspanolWide QRS complex tachycardias en Francais

| group16 = Business Resources on Wide QRS complex tachycardias | list16 = Wide QRS complex tachycardias in the MarketplacePatents on Wide QRS complex tachycardias

| group17 = Informatics Resources on Wide QRS complex tachycardias | list17 = List of terms related to Wide QRS complex tachycardias


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